Chp 69 - prep u
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
"I was brushing my teeth." Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision).
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
Apply an eye patch to the right eye. An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety.
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early.
Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply.
Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone)
Which is the primary vector of arthropod-borne viral encephalitis in North America?
Mosquitoes
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
Positive Brudzinski sign A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury) and flexion of the knees and hips is produced.
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.